This podcast episode is an interview with Ben Gold PT of Home Physical Therapy New York City. He has been working full time in his cash-based practice for over 3 years now and he has 3 independent contractor Physical Therapists currently working for him. All patients are treated in the comfort and convenience of their own home or office throughout New York City. He has done extremely well at carving a niche for his practice and quickly filling his patient schedule.

In this episode, you’ll learn about:

How Ben has carved a niche in providing home-based PT and is able to charge $260-$300 per treatment session.

Ben’s philosophy and tactics for finding and hiring good contractors/employees.

How he has developed Physician referral sources even though he is 100% out-of-network.

The right way to call to set up meetings with a potential new referral source.

How he is planning to move back to Australia but keep his business running in New York.

The big lessons and advice he has received from his highly successful patients

Great interview. Just a question on one small topic of the interview. There was mention of a practice owner working won the side with the cash based practice. Curious how this works for the patient to send in for reimbursement if the PT has his own NPI numbers already through his practice.

Hi Nate,
The EIN number is what the insurance companies care about for reimbursement, together with if the PT is in/out of network. I only hire out of network therapists who are also non-medicare providers. For each patient seen by one of my contractors, I put their individual NPI on the receipt. The patient simply sends the receipt in, together with the appropriate insurance reimbursement form and the process of payment (or denial) begins.

I have one question about the EIN and NPI numbers. Do you need one or both of these to have a cash-based PT practice that makes home visits? Is an NPI sufficient to create a statement for patients (along with the ICD-9 and treatment codes), or does the statement also need to have an EIN?

Before I listed both the NPI and the EIN numbers on my receipts, I’ve had insurance companies request one/both of them, so I would say that you do need both if you want to have the least issues with your patients’ self-claims getting denied.

I realize that I am very late to the party, as I only this week listened to this podcast. But my question relates to the question being posed here by Nate, and when asking it to others I have gotten no less than 3 different answers, so I wanted to ask here for more input. It seems like you have experience with this, Ben.

I am running a cash-based practice, but only part-time as it grows. I have created my own LLC, have obtained my own EIN, and give patients an invoice with CPTs and ICD-9s that they can submit on their own for reimbursement.

As my business is only part-time right now, I am also working at another facility PRN, and have an offer to work for a different one as well. What I am curious about is if I am considered an in-network provider with those other facilities that are not my own, does that affect my client’s potential for reimbursement at my own facility, even though at my place the charges are associated with a different EIN? And if that is the case, then that just means that my clients at my own practice would not be able to submit for out-of-network reimbursement, correct?

Hey Bill, I definitely want to hear Ben’s input on this, but my thoughts on this are as follows: If you are not individually listed in the contracts between the insurance companies and your employer, that contract should not apply to you when working in your own practice. I imagine the contracts they have only apply to the practice as a whole and to the individuals of that practice only for the work they do within that practice. Otherwise, anytime someone leaves or gets fired, they’d have to redo all their insurance contracts. With that said, I would definitely ask them if you are individually listed in their contracts with the insurance companies.

Thanks Jarod. That makes perfect sense to me and sounds reasonable. And I hope that is the correct answer as it definitely affords me more flexibility.

You and I have discussed this before, and just when I think I understand, somebody else throws something in that makes me doubt it. And I don’t know who is correct. Would be great to hear Ben’s feedback, or the feedback of anybody else who is doing the same thing as me.

First off, Jarod, love the podcasts. Even for a recent new-grad (May 2013), its got me motivated for possibilities in years to come after getting more experience.

Ben, I was impressed with your knowledge and business model and had a few questions. I work mostly home health now, but I’ve been looking to start my own side business. A lot of my current patient population and passion lies with geriatrics. Many of my older patients like the 1-on-1 personalized care in the home and are satisfied with the results they get with me as their therapist. Some request and even offer to pay cash for me to continue as their PT when the nurse and I begin telling them its time to go to outpatient. I’ve always brushed it off due to my perceived Medicare regulations, but looking at your website, it looks like you still see Medicare part B patients in home and have them submit for reimbursement. Can you fill me in on how you have made this work for you if you are completely OON? (Did you have to set up anything with CMS?, Do you have to submit these claims for them?, Is their anything different in your process of treating them compared to other OON insurance patients?, etc.)
Also, I know it changes state to state, but did you need to get any extra liability coverage or special licenses to provide healthcare in the home/office instead of the usual clinic setting?

The only Medicare patients I see are those ones who fill out an ABN who agree to not using their benefits for reimbursement. My contractors and I are not contracted Medicare providers anyway. Jarod has posted a few times about the legality of seeing Medicare patients or not on this website, so I’d probably check his previous posts on this topic.

I do not accept Medicare part B, but rather provide the appropriate forms for reimbursement. Why, you may ask, if I don’t get medicare reimbursement for seeing Medicare patients? In order for Medicare patients to get reimbursed from their secondary insurance company, they first need to show that medicare has denied payment – silly, I know. The patient first needs to send in for reimbursement from Medicare, and once this is denied send the denial and initial receipts to their secondary insurance company. How much they get back is an unknown. Some have received 50% of my fee and some have received $9 per visit.

I might add, that if I feel the patient cannot afford my fee i offer a heavily reduced rate for services to meet their needs.

There is nothing different in how I treat these patients from an administrative or clinical perspective. All patients receive 1 hour treatments. I do not submit any forms for reimbursement for these patients, but rather tell them that if they are having trouble a family member can help. This may sounds harsh, but if I spent all day dealing with insurance companies I wouldn’t have time to see patients.

In NY, HPSO provides extra liability insurance for seeing people in their home. I’d speak with an professional liability broker in your state for more info, as I am certainly no expert.

I was a little surprised to read the above response regarding Medicare, because I know of practices who have received “threatening” letters from CMS for providing skilled physical therapy to beneficiaries when the practitioner is not a Medicare provider. Have you been contacted by Medicare after one of your patients has sent in a self claim to them? One of the other statements in the above-mentioned letters from CMS, is that there is a “mandatory claims submission” law requiring that any claims on Medicare must be sent directly from the provider.

Have you had any feedback from CMS or the patients who have sent self-claims to them?

Hi Jarod,
In the past when I was dealing with Medicare I literally received different answers to these questions every time I called. To be honest, I don’t think they even knew the answers to these types of questions. All I can speak of is my limited experience with them thus far.

I have never received (and hope not to) a letter from CMS. I have not been contacted by Medicare, and none of my patients have.

What I do know, is that my patients have called Medicare to ask about reimbursement, and patients have been told to send in the submissions themselves. I know in the past Medicare have given them a hard time about reimbursement, but not due to anything you discuss above but rather general administrative issues. Again, if Medicare denies payment, I have successfully told them to resubmit to the secondary insurance and they have had some reimbursement via that avenue.

I recently had one patient lobby her local councilman as Medicare were giving her such a hard time. She was reimbursed 50c on the dollar for my services.

Again, this is why I try not to deal with Medicare directly. It seems to be a minefield of poor communication and misinformation.

WOW! It seems so hit or miss, and the one consistent thing that I hear over and over again is that 5 calls to Medicare will get you at least 3 different answers. So frustrating! I can only pass on here what I’ve learned from extensive research, attorney emails, etc and so far it kinda sounds like you’ve been getting lucky… hate to say that, but I definitely know of practices who have received the ol’ ‘cease and desist’ letter from CMS when patients have sent in self-claims for services from a clinic that doesn’t have a relationship with Medicare.

Dr Jarod,
Thanks to you and Ben for the great Podcast. I have been trying the same Home OP PT business, part time, on the other end of the spectrum from NYC, rural North Florida. I can’t approach the prices you can charge in NYC but I am curious about the pts. doing self billing. I currently have a cash based and ins. based practice. Those who pay cash just wasn’t a quick tx as they can’t afford a lot. With the pt doing there own billing how do you check for coverage, # visits, reimbursement or is that left up to the client? Do you let them check for pre approval?
Your Podcast inspired me again and I may have to move more City based. Thanks to you and Ben
Dan PT

Hi Dan,
I really deal with this on a case by case basis. In the initial waiver form I ask patients to fill out before treatment, there’s a part stating I am not responsible for patient reimbursement. If a patient has trouble getting reimbursed I help them of course. The standard things that take up my time from insurance co’s :
– address missing
– wrong diagnosis code
– tax ID missing
– the paper on the receipt is not recycled…

90% of these things are provided on the receipt the patient submits and this is the exact reason why I don’t rely on the insurance co for reimbursement. They are the bane of my existence.

That being said, I often verify insurance for patients to see how many visits they require. I encourage patients to ask their insurance company if they require pre-approval. I explain to the patient that their insurance company is more likely to give them a straight answer.

As an NYU grad, following this model in Vero Beach, FL, I appreciate the time that you & Ben Gold spent helping to change the landscape of PT. I would like to hear any tips on dealing with his wealthy clients ages 65+. (i.e. the billionaire with back pain with Medicare)

Hi Tamara,
Jarod is definitely the expert here. I think he has posted about this extensively. As I do not deal with Medicare administratively, I cannot really comment on what is covered and what is not covered.

Thanks Ben and Jarod for this informative interview. Since most of my questions re: Medicare have already been answered in prior posts, I was also wondering: What tools/equipment do you normally take with you to your visits? Portable table? You mentioned that you or your contractors may use public transportation so I was just wondering. Also would you comment on general pt demographics for your practice (pt age range, most common diagnoses requested for being seen in home or office, ?general income level, any others). Lastly, since some clients may not require a full hour (assuming this if they are not too involved) do you adjust your fee, say on minute increments (ie 15, 30, 45 etc) or does everyone straight up get 1 hr regardless.
Thanks!

Hey Christine, I’ll chime in and give my answer to your last question: Once in a while, if someone really seems like they don’t need a full hour of treatment, I will do a “half-session” but this is pretty rare. I tend to treat a great deal of the patients body, far away from the site of symptoms so I can almost always fill the hour with beneficial and needed treatment.

For those wondering about Christine’s mention of Medicare information, you can get a (Free) eBook of Cash-based PT and Medicare regulations by scrolling up this page and putting your email in the top right sidebar under the eBook image.

Hi Christine,
Our PTs do not carry table around with them, as I consider it an occupational hazard. If patients require many visits, I suggest they purchase a table for home use. Good portable tables range between $120-$140 – not bad for a table you’ll have for life.

Average age range of patients is probably baby boomer region. 95% are seen at their home. Income level I can’t comment on, as I never really ask. You can assume that they are not struggling though, if they can afford upfront payment for PT services.

Most common diagnoses for my therapists are post-op knee and shoulder surgeries.

Like Jarod, I only perform 1 hour treatments as I always find things to treat. I have considered reducing time/cost on occasions for specif patients.

Great question, Nick. I’m gonna let Ben field this one, since I only did home-based visits for about a month when starting out. The times I did see a female at her home, I made it clear that someone else needed to be present at home when I was there.

Hi Nick,
I’ve never had an issue with this. Essentially, we are professionals doing home visits – just like a doctor, massage therapist, acupuncturist etc going into someone’s home. I’ve heard bad stories about allegations against therapists in private consulting suites within a PT practice before. I’ve heard allegations of improper things going on in a PT gym. This is the reason we have liability insurance.

I think all we can do is behave in a professional manner bound by the code of conduct set by the APTA and document everything that goes on within the session. We also need to be aware of the potential “relationship” that begins in the patient’s mind when we begin to treat them. We are in a position of power when we treat a patient, especially if they are feeling vulnerable due to pain, relationship issues, anxiety etc. We must be careful to not take advantage of this, and to respect our duty of care..

That being said, it really is a tough one…I also believe that the potential issues you talk about may have to be the perfect storm of:

a) Inappropriate advances by either party
b) Boundaries not being set
c) Bad luck
d) Poor treatment decisions

If you feel things are not right after 1-2 sessions, and may turn pear-shaped, you should trust your intuition and stop seeing the patient.

I might add, Jarod’s suggestion of having someone being present in the home during the session is a good one.

Ben and Jarod thanks again for a great podcast!!
Ben, I am looking into a cash based model similar to yours and I was wondering how you handle documentation and billing with your contractors. Do you allow them to accept/ process payment or do patients pay you throughout their course of treatment? Do you use EMR or paper? Once a contractor has accepted a particular location do you set their schedule or are they responsible to do their own patient scheduling? How do pt’s communicate with you or your contractors? Do you give one main number for pt’s to call? Do your contractors give their personal contact number to pt’s? Do you charge pt’s for late cancellations( less than 24hr)?
Thanks again for all of the great information.
Stephanie